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Research Questions

  1. What standards should be used to identify high-quality care for veterans with posttraumatic stress disorder (PTSD), depression, substance use, and traumatic brain injury (TBI)?
  2. What is required to implement and disseminate standards for high-quality care?

Traumatic brain injuries and psychological health problems such as posttraumatic stress disorder, depression, and substance use, often referred to as invisible wounds, are common among U.S. military veterans who served in the era after September 11, 2001. Although there are effective treatments for these conditions, it has been challenging to identify places that provide such care, as there has not been a shared definition of what makes care high quality. In a previous study, high-quality care for invisible wounds was defined as care that is veteran-centered, accessible, and evidence-based and that includes outcome monitoring. Identifying standards to operationalize this definition is essential for improving access to high-quality, effective care. In this report, the authors recommend ten standards for the delivery of high-quality care for invisible wounds and provide considerations for implementing and disseminating these standards. Adoption of these standards of care would allow veterans, veteran-serving organizations, and payers to identify high-quality care providers and distinguish between good and poor care. The standards also provide a road map for providers that fall short of the benchmark and might need to invest in training and other resources to improve quality and demonstrate their ability to provide the best possible care for veterans living with invisible wounds.

Key Findings

High-quality care for veterans with PTSD, depression, substance use, and TBI should be veteran-centered, accessible, and evidence-based and should include outcome monitoring

  • Operationalizing this definition through standards of care can allow veterans, policymakers, providers, and payers to identify clinical providers who serve veterans and are currently delivering high-quality care. To be useful, standards must be both feasible (using data that are already being collected or could easily be collected with existing data collection methods) and considered to be an important element of high-quality care.
  • Through a literature review, interviews, and stakeholder ratings, the authors identified and recommended ten standards that were feasible to implement and measured important aspects of high-quality care.

The ten recommended standards of care for invisible wounds align with the definition of high-quality care and can be used to identify high-quality providers and programs

  • Veteran-centered care: Veterans report being told about treatment options. Program and clinic staff who interact with veterans have completed training in military cultural competence.
  • Accessible care: Care is available at no or minimal cost to veterans. Veterans who request a new outpatient appointment are seen within 30 days.
  • Evidence-based care: Veterans are assessed for suicide risk at each visit. Veterans with depression or PTSD receive evidence-based psychotherapy and/or pharmacotherapy. Veterans with substance use disorder are offered a psychosocial intervention. Veterans with co-occurring conditions receive integrated care. The program offers or facilitates coordinated, interdisciplinary rehabilitation for veterans with TBI.
  • Outcome monitoring: The program uses validated instruments to assess clinical symptoms during regular measurement periods.


  • Disseminate the definition and standards of high-quality care to providers, veterans, veterans' families, and other stakeholders.
  • Provide resources for quality improvement by facilitating or funding provider training—for example, staff training in military cultural competence and clinician training in using evidence-based forms of psychotherapy.
  • Incentivize quality improvement—for example, credentialing organizations could require reporting on metrics based on the standards, or payers could increase reimbursement rates or quality bonuses.
  • If unable to initially collect data to report on all ten standards of care, clinical providers or programs could consider starting with a minimum set of three standards: Demonstrate that veteran-facing clinical staff have received training in military cultural competence. Demonstrate that providers treating veterans with invisible wounds are providing evidence-based care. Collect data and report on timeliness to ensure that veterans seeking care can be seen by a provider within 30 days.

Research conducted by

This research was funded by the George W. Bush Institute, the Bob Woodruff Foundation, and Wounded Warrior Project and carried out within the Quality Measurement and Improvement Program in RAND Health Care.

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